Antero-lateral infarct To Arrest.

mrhunt

Forum Lieutenant
180
27
28
So just another one of my typical Call reviews / scenarios type of thing.

60yo M, A&0X4 GCS15 called for shortness of breath. Pt seems almost like a drug induced sort of Presentation, Rolling around on the bed really just "playing it up" but am on the fence weather he's just in SEVERE distress or playing it up. Very agressive and non-compliant with assessment questions, Overall home enviornment and family members suport this suspicon as well.

initial vital signs are unable to be obtained due to pt LITERALLY constantly moving and rolling around and yelling.
We get him on a tarp and carry out, and He goes limp and GCS3 with agonal respirations like 10 seconds before getting him onto the gurney.

In back of the ambulance 4 lead shows sinus bradycardia @ 30 with a palpable carotid pulse still , BVM and OPA intiated. Partner is placing pt on pads, BP, SP02, ETC02 and hooking up a 12 lead,
Im working on IV access simultaneously (2 attempts failed) and jump to an IO which is successful. 12 lead shows antero-lateral infarct with tombstone elevations in 1, AVL, V3,4,5,6. We actually get a BP somehow of 117/60, Skins are Literally Grey and cool, Pupils PERRL @ 3mm, lungs Clear, Fire gets a blood sugar which is unremarkable, Narcan considered but not given as this clearly appears cardiac in nature. Prior history of Bacterial pneumonia and thats about all.

By the time my initial vitals are back and pt is fully on the monitor he's coded and Now in PEA.
CPR Started, No shocks given or advised. No epi able to be given as transport time to the Hospital less than 2 minutes and Doing 1 handed CPR while giving radio reports.

SO i feel like i Could have POSSIBLY started pacing him sooner, maybe i just feel guilty though. Do you think if i had of started pacing him sooner it could have prevented him coding?

Cause the other half of me feels like half of the pt's heart completely lost blood flow and he was sorta ****ed, and even if i WAS able to pace him before he coded, i would have ended up pretty quickly pacing a dead person.

Anyways, Hospital got back ROSC several times but ultimately called it as they were just epi-pulses, and ER staff said theyre 12 lead was also Just devastatingly bad / essentially no hope for the guy.


Questions? Anything you would have done differently?
 

Rano Pano

Forum Lieutenant
229
82
28
Granted I’m tired so I apologize if I missed this but when exactly did you pace him?
Immediately after noticing you had a rate of 30 in a unconscious pt?
 
OP
M

mrhunt

Forum Lieutenant
180
27
28
He wasnt paced. He went from GCS 15 > GCS 3 > Dead within a matter of 30 seconds.

By the time pads were applied and i even got on the monitor, He lost pulses. Thats what im saying, i dont really think i COULD have done anything any faster, So pacing wasnt initiated cause i would have been pacing a dead guy at that point.
 
OP
M

mrhunt

Forum Lieutenant
180
27
28
My point / Mindset, is that if i WAS able to start pacing him before he coded, he was brady from the stemi. And i dont know if increasing his heart rate via pacing would have done anything to PREVENT him from going into arrest or not....Or if it would have just pissed off his heart even more and he would have coded regardless.
 

Jim37F

Forum Deputy Chief
4,022
2,584
113
I'm wondering why if you had Fire on scene, and a 2 minute ride to the hospital, why not take a Fire rider to be your manual Lucas device while you did the radio and everything else instead of all that and ineffective one handed compressions at the same time, that almost certainly did no good?
 
OP
M

mrhunt

Forum Lieutenant
180
27
28
I had my medic Intern doing manual IO, I was doing CPR for him and radio report and Airway managed by Fire. So thats 3 people in the back of a sprinter ambulance that is already Incredibly tight quarters. Wouldnt have been physically possible for a 4th.

A radio report was probally 15 seconds so thats how long my CPR was ineffective for, Just to clarify.
"STEMI that coded enroute, CPR in progress, BVM and working on a line, ETA 2 minutes". That was literally my report, ****ty? i suppose but it got the point across pretty well.
 

Rano Pano

Forum Lieutenant
229
82
28
From what you’ve shared it sounds like you did what you or anyone else could of done.

Prevented? Probably not the word I’d go with. I’ve had similar situations - ventricular rhythm - TCP going within seconds - they died. Likewise there’s a reason we pace and I’ve also seen great outcomes with it.

I rarely look at this job with the perspective that anything I did or didn’t do (within reason) contributed to someone living or dying. I choke on my spit every other day, ya know? Im here to help however I can on critical calls but having a impact on life or death ….no way… that’s beyond me. Just me though.
 

Tigger

Dodges Pucks
Community Leader
7,551
2,506
113
Yes you should pace this patient immediately upon finding profound bradycardia. Getting a full set of vitals, 12 lead, missing two IVs, and starting an IO is too long to not be treating the rate. Would it have mattered? I have no idea, probably not.

But we don’t practice medicine based on the “well they died anyway model.”
 

Aprz

Forum Deputy Chief
Premium Member
2,858
553
113
Yes you should pace this patient immediately upon finding profound bradycardia. Getting a full set of vitals, 12 lead, missing two IVs, and starting an IO is too long to not be treating the rate. Would it have mattered? I have no idea, probably not.

But we don’t practice medicine based on the “well they died anyway model.”
Don't forget the blood sugar! Lol.

I'm gonna be the crazy one here, but honestly, with a GCS of 3, I probably would've just treated them like a cardiac arrest without pacing. I think the odds of someone imagining a pulse that isn't really there is very high with this patient. I also doubt you guys successfully got a manual blood pressure with this patient. I especially wouldn't trust someone who verbally told me the patient's blood pressure was 117/60 so I am guessing it was the monitor that got the blood pressure. LifePak is a very common monitor. I used to jokingly tell people that the only time LifePak wouldn't complain, wouldn't give me a bad blood pressure, was when the patient was dead. It's seriously like the AllState Commercial with Mayhem.


Patient: *dead*
LifePak15: You're good. 120/80.

To put a cherry on top of all of this, I think most people are lousy at pacing patient. They'll put the pads in the typical anterolateral spot for cardiac arrest rather than anteroposterior spot for pacing. They don't know how high the mA should be so they think they got capture at 10 mA. They'll be completely unaware of what phantom QRS is

JXUGbSY.jpg


example of phantom QRS

and think they got capture because they see phantom QRS. They'll be unaware that they have intermittent capture at the same rate, that pacing wasn't successful at increasing the heart rate. I think pacing has a much higher failure rate than we are lead to believe, and I think most people wouldn't recognize that pacing has failed. For a patient like this, GCS of 3, very bradycardic, LifePak telling you "you're good. 120/80 bro", someone telling you they feel a pulse or you feeling one that probably isn't really there... I personally think they should be treated like a cardiac arrest instead. I don't know... I've just seen it too many times. I am very wary about pacing these type of patients.
 
Last edited:
OP
M

mrhunt

Forum Lieutenant
180
27
28
So to be clear as well, the only reason why ALL of that was done is because the Emt wasnt the best, And She started doing all vitals EXCEPT for pads first.....Hence the full set of vital signs done. So while medic intern was waiting on pad placement (which she also struggled with a tad) he tried 2 iv's which was probally only about 30 seconds tops, And then realized what she was doing and just put the pads on himself....

I completely agree with you that the pt should have been paced immediately. We did it as immediately as We were able to, Granted not fast enough though.

But by that time it was too late. He was also simultaneously getting fire to bag, Getting a helicopter on standby and making base with a STEMI center.

But tigger, i completely agree with you and Wasnt trying to ever do a "well they died anyway" type of thing. My whole point was to ask if you / Everyone think FASTER pacing would have made a difference in this pt coding or not.
 
OP
M

mrhunt

Forum Lieutenant
180
27
28
Don't forget the blood sugar! Lol.

I'm gonna be the crazy one here, but honestly, with a GCS of 3, I probably would've just treated them like a cardiac arrest without pacing. I think the odds of someone imagining a pulse that isn't really there is very high with this patient. I also doubt you guys successfully got a manual blood pressure with this patient. I especially wouldn't trust someone who verbally told me the patient's blood pressure was 117/60 so I am guessing it was the monitor that got the blood pressure. LifePak is a very common monitor. I used to jokingly tell people that the only time LifePak wouldn't complain, wouldn't give me a bad blood pressure, was when the patient was dead. It's seriously like the AllState Commercial with Mayhem.


Patient: *dead*
LifePak15: You're good. 120/80.

To put a cherry on top of all of this, I think most people are lousy at pacing patient. They'll put the pads in the typical anterolateral spot for cardiac arrest rather than anteroposterior spot for pacing. They don't know how high the mA should be so they think they got capture at 10 mA. They'll be completely unaware of what phantom QRS is

JXUGbSY.jpg


example of phantom QRS

and think they got capture because they see phantom QRS. They'll be unaware that they have intermittent capture at the same rate, that pacing wasn't successful at increasing the heart rate. I think pacing has a much higher failure rate than we are lead to believe, and I think most people wouldn't recognize that pacing has failed. For a patient like this, GCS of 3, very bradycardic, LifePak telling you "you're good. 120/80 bro", someone telling you they feel a pulse or you feeling one that probably isn't really there... I personally think they should be treated like a cardiac arrest instead. I don't know... I've just seen it too many times. I am very wary about pacing these type of patients.
And APRZ, I also completely agree with you as well. Theres a very real chance he Coded While we were carrying him to the gurney. It was a tad strange to think he dropped to GCS 3 with agonal respiration's and still had a pulse rate in 30's to 40's. Ive had a few symptomatic bradycardia's that were clearly BAD, but never stopped breathing and turned into a potato. My medic intern said he felt a carotid at that time so i believed him. but if we had of started pacing theres a good chance we COULD have been pacing a dead guy at that point.

Also blood pressure was clearly ******** as well. Agree with you there. And it was off the zoll and not a manual.

But it all worked out in the end (or didnt ultimately since he's dead), and no call is perfect which is why i love these discussions with you guys since it helps make me a better medic. We never stop learning or growing!
 

Akulahawk

EMT-P/ED RN
Community Leader
4,742
1,143
113
Given the totality of the circumstances, I think you did the best you could under the conditions you were in at that particular time. What this call might do for you down the road is focus perhaps on getting the pads ready to go a little quicker when you see such extensive tombstones and perhaps go for a single PIV attempt before going IO if the patient codes. This is all just probably unrealistic but I think that if you're seeing someone go from a more normal rate to a significant brady, just reach for the pacer pads and get ready to work a code. I saw something similar to that a couple weeks ago. Normal-ish rate to severe brady in the 30's, worked the code and because we were seriously lucky this was caught so early, we got ROSC. Wasn't my patient, so I don't know the entire backstory.
 

silver

Forum Asst. Chief
894
102
43
So to be clear as well, the only reason why ALL of that was done is because the Emt wasnt the best, And She started doing all vitals EXCEPT for pads first.....Hence the full set of vital signs done. So while medic intern was waiting on pad placement (which she also struggled with a tad) he tried 2 iv's which was probally only about 30 seconds tops, And then realized what she was doing and just put the pads on himself....

I completely agree with you that the pt should have been paced immediately. We did it as immediately as We were able to, Granted not fast enough though.

But by that time it was too late. He was also simultaneously getting fire to bag, Getting a helicopter on standby and making base with a STEMI center.

But tigger, i completely agree with you and Wasnt trying to ever do a "well they died anyway" type of thing. My whole point was to ask if you / Everyone think FASTER pacing would have made a difference in this pt coding or not.

Possibly. People talk of the bradycardic periarrest death spiral. Physiologically the bradycardia -> more low CO/hypoperfusion -> more ischemic myocardium -> more bradycardia.
 

johnrsemt

Forum Deputy Chief
1,489
211
63
1st of all: what are your protocols?
Do they say to pace a brady patient with a good BP (yes the BP may have been bogus, but you have to go with what you have)? Some do, but a lot say to give them a fluid bolus and Atropine.

Yes you had a fast code, and fast transport: sit and look back at it if you had a 30 minute transport and 2 Medics and a good Basic; what would you have done different in the back of the truck with the protocols that you have?
Then decide if you did anything wrong.
 

Tigger

Dodges Pucks
Community Leader
7,551
2,506
113
I would pace this patient even with the posted blood pressure. Even if it is accurate, they’re unconscious. Fix the problem.
 

wcspa

Forum Probie
21
11
3
I do not think you could have done anything different that would have made a meaningful difference in outcome. Given the rapidity of the decline for the patient, I sincerely doubt you beginning pacing would have altered their trajectory. The patient was having a massive myocardial infarction which killed them. This patient could have been on the table in the cath lab and being the same result would have likely happened.

Many patients die regardless of your interventions even if performed perfectly and timely and I suspect this patient falls into this class.
 

johnrsemt

Forum Deputy Chief
1,489
211
63
Remember the 1st 2 rules of EMS:
#1: Patients die,
#2: We can't always fix #1.

Also: As Tigger says: Pace, but due to the patient condition, not due to the BP: (I just re-read the OP); patient looks like crap, treat the patient not the monitor. Do what you can to fix it, although in this case not much you can do to fix it. and as WCSPA said, they would have probably died anyway.
 

Tigger

Dodges Pucks
Community Leader
7,551
2,506
113
We gotta get away from the “they would have died” or “you can’t make em’ deader” mentality.

There’s a most correct way to treat these patients, you need do it. Hard stop.
 

RocketMedic

Californian, Lost in Texas
4,899
1,373
113
Very similar call to this last tour. 54 F, anterolateral MI. Four separate ROSCs but couldn’t sustain. Also had some weird Lucas-driven neuro activity intraarrest.
 

E tank

Caution: Paralyzing Agent
1,331
1,121
113
To put a cherry on top of all of this, I think most people are lousy at pacing patient. They'll put the pads in the typical anterolateral spot for cardiac arrest rather than anteroposterior spot for pacing. They don't know how high the mA should be so they think they got capture at 10 mA. They'll be completely unaware of what phantom QRS is
and think they got capture because they see phantom QRS. They'll be unaware that they have intermittent capture at the same rate, that pacing wasn't successful at increasing the heart rate. I think pacing has a much higher failure rate than we are lead to believe, and I think most people wouldn't recognize that pacing has failed. For a patient like this, GCS of 3, very bradycardic, LifePak telling you "you're good. 120/80 bro", someone telling you they feel a pulse or you feeling one that probably isn't really there... I personally think they should be treated like a cardiac arrest instead. I don't know... I've just seen it too many times. I am very wary about pacing these type of patients.
You can pace effectively without A/P pad placement and a glance at the pulse ox pleth will indicate capture or not. Those things aside, if there are folks that are not trained well in external pacing, how well trained can they be in treating a full arrest?

Pace when indicated.
 

Top